The Patient is a 72 year old AA male serving a life sentence for Arson Willful Damage. TRD: 9999 Entered FDOC: 11/3/78
II REASON FOR ADMISSION: Inmate was admitted to Lake CI TCU on 6/6/12 due to patient has been refusing all services and treatment , including psychotropic medication. Pt has a history of active schizpaffective D/O as evidenced by thought blocking and self-isolation. Patient is refusing medications due to his paranoia, and he is very guarded and suspicious, and refusing to come out of his cell for services.. III RELEVANT MEDICAL & MENTAL HEALTH HISTORY: See TCU medical chart. Mental Health Hx: Per records indicate that he miltiple inpatinet admission such as MHTF/CSU/TCU. Records indicate hthta IM was un-cooperative …show more content…
CURRENT MENTAL STATUS EXAM: Patient was seen on 5/17/17 by his MHP/Case Manager on MHTF wing. On that day, inmate appearance was dressed appropriately, good hygiene, and good eye contact. His affect was broad with intermittent smiling. Inmate was receptive & cooperative. He was alert & oriented X4. No gross memory deficits. Speech normal rate & tone. He denied any suicidal and homicidal ideation with no intent or plan when asked. The inmate is eating 3/3 meals & achieving 7-8 hours of sleep when asked by MHP.
VI. DISCHARGE DIAGNOSIS:
ICD-10: ISP# patient has been diagnosed with F20.90 Schizophrenia; F60.2 Antisocial Personality D/O.
VIII CURRENT MEDICATIONS: None
VII RECOMMENDED. Patient is recommended to transfer from Lake TCU to TCU due him no longer meeting criteria for inpatient treatment. Without the use of psychotropic medication this inmate has remained asymptomatic. It is recommended that treatment continues to focus on ISP goals 308 dischage Readiness Skill-, #153 Thought D/O , #110 Delusion, # 306 Social Skill Deficits. Inmate will receive regularly scheduled counseling, and group sessions as an S-4 inmate; however, his MDST believes a change in scenery may be of benefit to him as he appears to have progressed to the fullest extent likely at Lake
II REASON FOR ADMISSION: Inmate was admitted to Lake CI TCU on 6/6/12 due to patient has been refusing all services and treatment , including psychotropic medication. Pt has a history of active schizpaffective D/O as evidenced by thought blocking and self-isolation. Patient is refusing medications due to his paranoia, and he is very guarded and suspicious, and refusing to come out of his cell for services.. III RELEVANT MEDICAL & MENTAL HEALTH HISTORY: See TCU medical chart. Mental Health Hx: Per records indicate that he miltiple inpatinet admission such as MHTF/CSU/TCU. Records indicate hthta IM was un-cooperative …show more content…
CURRENT MENTAL STATUS EXAM: Patient was seen on 5/17/17 by his MHP/Case Manager on MHTF wing. On that day, inmate appearance was dressed appropriately, good hygiene, and good eye contact. His affect was broad with intermittent smiling. Inmate was receptive & cooperative. He was alert & oriented X4. No gross memory deficits. Speech normal rate & tone. He denied any suicidal and homicidal ideation with no intent or plan when asked. The inmate is eating 3/3 meals & achieving 7-8 hours of sleep when asked by MHP.
VI. DISCHARGE DIAGNOSIS:
ICD-10: ISP# patient has been diagnosed with F20.90 Schizophrenia; F60.2 Antisocial Personality D/O.
VIII CURRENT MEDICATIONS: None
VII RECOMMENDED. Patient is recommended to transfer from Lake TCU to TCU due him no longer meeting criteria for inpatient treatment. Without the use of psychotropic medication this inmate has remained asymptomatic. It is recommended that treatment continues to focus on ISP goals 308 dischage Readiness Skill-, #153 Thought D/O , #110 Delusion, # 306 Social Skill Deficits. Inmate will receive regularly scheduled counseling, and group sessions as an S-4 inmate; however, his MDST believes a change in scenery may be of benefit to him as he appears to have progressed to the fullest extent likely at Lake